Monday, April 14, 2008

zombie

i was on call. my house doctor called me to casualties. she wouldn't tell me over the phone why. she just said i must come and see for myself.

whenever i went to casualties i went through a specific routine. i read the referral. then, if there are x-rays, i look at them and discuss them with the students. then i go to the patient.

the referral was strange. it was for a facial ulcer. but they mentioned that the patient was known to the vascular department, almost as if it was something that they remembered afterwards. i was a bit annoyed. why all the fuss about an ulcer? anyway, who comes to casualties in the middle of the night with an ulcer?

"here is the arteriogram they came in with." there's an arteriogram? i thought. ok. at least something to show the students. i gathered them around, telling the final years they'd have to read the x-rays. then i put them up. i was astounded.

it was an aorta and outflow. but all that i could see..all that was there in fact.. was the aorta and one renal artery. there were no visible vessels to the arms or legs. if you looked carefully you could see faint vertebral vessels snaking their way up to the brain. but there were no carotids (the normal dominant arteries in the neck going to the brain). if these x-rays are accurate, i thought, then the patient should have no palpable pulse. i was no longer annoyed.

i went down the casualties passage. from a distance i identified the patient. in a wheelchair was an ashen faced man with blue lips. he only had one arm and half a leg. obviously his vascular condition had already claimed the other limbs in the past. on his one cheek he did not have an ulcer but a large full thickness necrotic (dead tissue) area. i greeted him. he opened his eyes and moaned something in reply. his caregiver (his daughter if i remember correctly) told me that he was known to vascular and gave me a letter that they had written on his last discharge. as i expected they concluded that they could do nothing more for him and had essentially discharged him to die.

while we were chatting, i saw a junior nursing student approach the patient to take his vitals. i considered telling her that she would find no signs of life except consciousness but the imp in me took over and i watched on in silence. sure enough the more she looked for a pulse the wider her eyes got. but the man was still responding to her, so she could not conclude that he was dead.

i then examined him myself. he had absolutely no palpable pulse anywhere on his body, including all central pulses. i listened with a stethescope. his severe emphysema meant that there was a large piece of lung over the heart and no heart sounds could be heard. also due to the emphysema, no breath sounds were audible. there were truly no discernible signs of life. and a large area on his face had died and was rotting off. but he was awake and even lucid to a degree.

i was amazed. it was tragic to the extreme. and yet i couldn't help noticing the similarities between a so called zombie and this man. we could not document any clear indication that he was alive. and yet he was alive because. . .well he was alive if you spoke to him.

i considered what i could do for him. if i debrided the necrosis on his cheek, there would be a big hole through which his teeth would be clearly visible. that would only add to his zombie-like appearance. besides he would not survive any form of anesthetics. i had to face the fact that the vascular department had already faced. there was no helping him. in the end we adjusted his pain medication (quite a bit) and sent him on his way.

When I was an intern in the county hospital ER, I once admitted a man to surgery who was very elderly and unresponsive, and had the most literal board-like abdomen I've ever felt. My admitting diagnosis was "Perforated viscus; r/o death."

Followers

other

Technorati

blogburst

this blog was the runner up in the literary category of the 2009 and 2010 medical weblog awards

blog awards????

disclaimer

the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.